Sequence of Payment and Informational Modifiers

Basics of Modifiers

Modifier plays a key roles in modification of procedure and also in the proper payment. Modifiers helps in changing or altering the procedure based on the scenario or situation the exam is performed. We all know their are different payment and instructional modifiers. Payment modifiers direct affect the payment hence should be used very carefully. Today we will learn about how to sequence the modifiers when two or modifiers are used with CPT codes. Please checkout out some basics about modifiers in below links before going ahead.

Use of 25, 24 and 23 modifiers with E/M CPT codes

Advance coding guide for X modifiers

Use of 76 and 77 modifiers

When to use 58, 78 and 79 modifiers

Modifier 62 v/s 80 modifier

Modifiers and Their Use

Modifiers are always two characters, which can be numeric, alpha, or alphanumeric. Some healthcare organizations create internal three-character modifiers, which are typically used for data collection and reporting purposes.

Modifiers exist for almost every special situation. For example (not an inclusive list):

Evaluation and management (E/M) service was significant and separately identifiable from a procedure on the same day (25)
Identification of a specific body area (E1 through F9)
Identification of laterality (RT, LT)
Designation of bilateral procedure (50)

Repeat service by the same or different provider (76, 77)
Increased procedural services (22)
Reduced service or discontinued procedure (52, 53)
Identification of professional or technical only component (26, TC)
Service provided by a resident under physician’s supervision (GC, GE)

These modifiers are separated into two categories:

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Payment modifiers: These directly affect the pricing or payment of a service. When reporting more than one modifier, the payment modifier should be placed in the first modifier Payment modifiers 22, 24, 25, 26, 50, 52, 53, 54, 55, 57, 58, 59, 62, 78, AA, AD, TC, QK, QW, and QY affect reimbursement and must always be supported by documentation in the medical record. Overutilization of these modifiers may raise a red flag and prompt payer audits or reviews.

Nationally, overutilization of modifiers 22, 25, and 59 has prompted both the Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) to conduct medical claims reviews. The OIG is expected to publish a report in 2022 on E/M services billed with modifier 25 in conjunction with same-day minor surgical procedures performed by a dermatologist.

Informational/statistical modifiers: These are placed in the second modifier position. Generally, HCPCS Level II modifiers are reported in the second position when reported with CPT modifiers. The same applies to lateral- ity modifiers.

For example, if a surgical CPT code is reported that requires a laterality modifier (RT, LT) and the surgical procedure is also a difficult or unusual procedure,modifier 22 should be placed in the first modifier position and modifier RT or LT in the second modifier position.

Coding tips for Successful Modifier Use

Here are a few strategies you can implement for proper use of Modifiers:

Educate coders, billers, and providers on proper modifier
Utilize an encoder, such as AAPC’s Codify, to validate CMS NCCI CPT/HCPCS Level II modifier combinations upon claim
Build payer-specific CPT/HCPCS Level II modifier combinations into your practice management system. Claim edits are less expensive to work than claim
Work claim edits and claim denials daily; fewer days in accounts receivable equals higher

Perform a billing and coding documentation audit at least annually, either internally or by enlisting the help of an outside organization.